title: Postoperative chyle leak after major pancreatic resections in patients who receive enteral feed: risk factors and management options.
abstract: BACKGROUND
  Chyle leak complicates 1.3-10.8 % of pancreatic resections. Universal use of parenteral nutrition following pancreatic resection may reduce the incidence of chyle leak. However, this denies the majority of patients who do not develop chyle leak the benefits of enteral nutrition (EN). The present study aimed to identify risk factors for chyle leak following pancreatic resection within a single institution where EN was used universally.
  
  
  METHODS
  All patients who underwent pancreatic resection between January 2007 and December 2010 were identified retrospectively. The patients had been treated according to a common unit protocol of enteral feeding; those developing chyle leak were switched to a medium-chain triglyceride (MCT) regimen. Clinical progress and recovery after surgery was evaluated. Multivariate analysis was performed to identify factors associated with chyle leak.
  
  
  RESULTS
  A total of 245 patients underwent major pancreatic resection (231 pancreatoduodenectomy, 14 total pancreatectomy). Chyle leak complicated 40 cases (16.3 %). After multivariate analysis, both extensive lymphadenectomy (P = 0.002) and postoperative portal/mesenteric venous thrombosis (PVT) (P = 0.009) were independently linked with a higher incidence of chyle leak. The development of chyle leak was not associated with poorer survival or prolonged duration of hospital stay. It was associated with a significantly increased duration of abdominal drainage and reduced likelihood of early hospital discharge (P = 0.026).
  
  
  CONCLUSIONS
  Universal use of enteral feeding is associated with a high rate of chyle leak following pancreatic resection. Patients undergoing extensive lymphadenectomy or those who develop PVT postoperatively are at increased risk. Development of chyle leak was not associated with additional morbidity or mortality following implementation of an MCT regimen. The implication is that reactive management of chyle leak with conversion to a MCT predominant diet is safe.
authors.affiliation: Hepatobiliary and Pancreatic Surgical Unit, Department of Surgery, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK, abuhilal9@gmail.com.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Abu Hilal
authors.forename: David M
authors.initials: DM
authors.lastname: Layfield
authors.forename: Francesco
authors.initials: F
authors.lastname: Di Fabio
authors.forename: Irantzu
authors.initials: I
authors.lastname: Arregui-Fresneda
authors.forename: Ioanna G
authors.initials: IG
authors.lastname: Panagiotopoulou
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Armstrong
authors.forename: Neil W
authors.initials: NW
authors.lastname: Pearce
authors.forename: Colin D
authors.initials: CD
authors.lastname: Johnson
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002913:Chyle; D004322:Drainage; D004750:Enteral Nutrition / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010180:Pancreatectomy; D016577:Pancreaticoduodenectomy; D010289:Parenteral Nutrition, Total; D011182:Postoperative Care / Q000009:adverse effects* / Q000379:methods; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome